The nurse applies a moisture-retentive dressing to a client's wound. The nurse understands that the main advantage of this dressing, rather than a wet dressing, is its ability to:

Provide autolytic debridement.

Decrease epidermal resurfacing.

Enhance the absorption of topical medications.

Promote the formation of a protective scab that traps excess exudate.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Autolytic debridement is the natural process by which the body breaks down and removes dead tissue. Moisture-retentive dressings create an optimal environment for this process, facilitating wound healing.

Choice B rationale

Decreasing epidermal resurfacing is not a recognized benefit of moisture-retentive dressings. These dressings aim to promote healing, not inhibit epidermal growth.

Choice C rationale

While moisture-retentive dressings can help with the absorption of topical medications, this is not their main advantage. The primary benefit is creating a conducive environment for autolytic debridement.

Choice D rationale

Promoting the formation of a protective scab that traps excess exudate is not the main advantage of moisture-retentive dressings. In fact, these dressings help manage exudate and reduce the risk of infection without forming a scab.

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Correct Answer is ["A","B","C"]

Explanation

Choice A rationale

Documenting wound size includes measuring the length, width, and depth of the wound to track the healing process and plan appropriate interventions.

Choice B rationale

The wound bed should be assessed for tissue type (granulation, slough, or eschar), color, and the presence of any exudate or infection.

Choice C rationale

The periwound skin is the area around the wound which should be assessed for color, temperature, swelling, and signs of maceration or excoriation.

Choice D rationale

Pattern of eruption is more relevant to dermatological conditions such as rashes or lesions, and not a primary focus for documenting acute open wounds.

A. Deficient fluid volume. B. Excessive intake of convenience foods. C. Constipation. D. Infection.

Correct Answer is C

Explanation

Choice A rationale

Deficient fluid volume is not the primary concern related to weight loss or ill-fitting dentures. While fluid intake should be monitored, it is less immediate than gastrointestinal issues from fiber deficiency.

Choice B rationale

Excessive intake of convenience foods might relate to weight loss but does not directly indicate a health risk. The primary risk is more focused on gastrointestinal function.

Choice C rationale

Constipation is a major risk due to limited fiber intake. Fiber is essential for bowel movement regularity, and its deficiency, coupled with ill-fitting dentures, increases the risk.

Choice D rationale

Infection is not directly related to the dietary concerns noted. While poor nutrition can weaken the immune system, it is not the most immediate health risk connected to the given symptoms. .

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The nurse applies a moisture-retentive dressing to a client's wound. The nurse understands that the main advantage of this dressing, rather than a wet dressing, is its ability to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse documenting an acute open wound should include which characteristics? Select all that apply.

Correct Answer is ["A","B","C"]

Explanation

Correct Answer is C

Explanation

The nurse assesses two new wounds located on a client's right and left buttocks. Which intervention for wound management would the nurse employ? Select all that apply.

A nurse is assessing a client with impetigo. The nurse would most likely observe which of the following?

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